Provider Demographics
NPI:1912996414
Name:WEAK, LANNIE L JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LANNIE
Middle Name:L
Last Name:WEAK
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 S 25TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1764
Mailing Address - Country:US
Mailing Address - Phone:402-731-2100
Mailing Address - Fax:402-731-2100
Practice Address - Street 1:4620 S 25TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1764
Practice Address - Country:US
Practice Address - Phone:402-731-2100
Practice Address - Fax:402-731-5179
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE54801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice